Integrated Care Plan for Health Care Quality and Access

Overseen By Harpreet K Jaswal, MPH

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University of Calgary

Disqualifiers: Active psychosis, Suicide risk, Intoxication, Critically ill, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 7

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to improve the transition from hospital to home care using an Integrated Care Pathway (ICP) model. The goal is to reduce hospital readmissions and emergency visits while ensuring continuous care and support, particularly for those with chronic health issues or social challenges. Participants will receive a personalized care plan and ongoing support from a dedicated care team. Patients in Calgary with multiple health conditions or social challenges that hinder access to healthcare might be a good fit. The study will compare this new care model with traditional methods to evaluate its effectiveness. As an unphased trial, this study offers participants the chance to contribute to innovative healthcare solutions that could enhance care transitions for many.

Do I need to stop my current medications for this trial?

The trial information does not specify whether you need to stop taking your current medications. It seems focused on care coordination rather than medication changes, so you may not need to stop them, but it's best to confirm with the trial coordinators.

What prior data suggests that this integrated care plan is safe for patients?

Research has shown that integrated care plans aim to improve patient safety and the quality of care. These plans help patients manage their health better and reduce hospital visits. Studies have found that when hospitals focus on safety, patient outcomes improve, leading to a safer and more positive experience for patients.

Integrated care involves close teamwork among different healthcare providers to ensure patients receive consistent care. This approach supports patients from their hospital stay through their transition home, reducing the risk of complications or needing to return to the hospital. Since integrated care focuses on better organization and communication among care teams, it generally doesn't pose direct health risks to patients.

In summary, integrated care plans are designed to enhance safety and support, making them well-received by patients. While specific data from this trial isn't available, existing research supports the safety and benefits of such coordinated care models. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about the Integrated Care Plan because it offers a comprehensive, coordinated approach to patient care that differs significantly from traditional methods. Unlike standard care, which often involves separate and disconnected healthcare services, this plan fosters seamless collaboration among a patient's entire care team, including primary care, home care, and hospital services. This integration is designed to ensure continuity of care during hospital stays and when transitioning back home, potentially reducing service duplication and addressing unmet needs more effectively. By co-designing a personalized care plan with the patient and incorporating it into their medical records, the Integrated Care Plan aims to improve patient outcomes and optimize the use of healthcare resources.

What evidence suggests that the Integrated Care Plan is effective for reducing hospital readmissions and improving continuity of care?

Studies have shown that integrated care pathways (ICPs), like the one tested in this trial, can make healthcare more consistent and improve patient outcomes by coordinating medical and social care. Research indicates that ICPs help reduce hospital readmissions and emergency room visits by ensuring a smooth transition from hospital to home. Participants in this trial will have a dedicated care team supporting them during their hospital stay and recovery at home. Moreover, ICPs improve communication between healthcare providers, leading to more efficient use of resources and better patient experiences. These pathways also aim to improve access to necessary services, crucial for patients with complex health needs. ^{6 7 8 9 10}

Who Is on the Research Team?

Michelle Grinman, MD FRCPC MPH

Principal Investigator

University of Calgary

Are You a Good Fit for This Trial?

This trial is for patients at high risk of hospital readmission and with medical or social vulnerabilities admitted to general medical units in Calgary hospitals. It aims to improve care quality and access, focusing on those who might benefit from an integrated care plan.

Inclusion Criteria

I can make my own medical decisions or have someone who can.

Patients must reside in Calgary Zone

Patients must be community-dwelling

Exclusion Criteria

I am 17 years old or younger.

I am admitted to a surgery, obstetrics/gynecology, or psychiatric ward.

Patients without valid health coverage data

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Hospitalization and Discharge Planning

Participants are assigned to an ICP team member who supports discharge planning and advocates for their needs during hospitalization.

Varies based on hospitalization

Continuous in-hospital support

Post-discharge Support

Participants receive 24-hour phone support for the first 2 weeks post-discharge and long-term support up to 90 days to implement and adapt the complex care plan.

Up to 90 days

Phone support and community follow-up

Follow-up

Participants are monitored for safety and effectiveness after discharge, with follow-up visits to primary care and subspecialty care.

3 months

Follow-up visits at 7 days, 1 month, and 3 months

What Are the Treatments Tested in This Trial?

Interventions

• Integrated care plan

Trial Overview The study tests the Integrated Care Pathway (ICP) model against usual care. ICP includes a personalized team member support during hospitalization, intensive case management, post-discharge phone support within two weeks, and community follow-up for up to 90 days.

How Is the Trial Designed?

Group I: Integrated care pathway supported by the integrated care lead Experimental Treatment 1 Intervention

Enrolled patients in the ICP will then undergo more assessment by the Integrated Care Lead to develop a preliminary inventory of their needs for transitioning back to their health home. Patients will then be assigned an Integrated Care Lead with expertise in managing their particular needs. This will result in the development of a complex care plan that is co-designed with a patient's acute and community care team (eg: primary care, home care, community services, hospital medical team etc). This plan will be documented in Connect Care and incorporated into the discharge summary at the time of hospital discharge. (see Appendix 2) Calgary Zone Integrated Care Program will then provide: * Continuity of care with the assigned ICP team member(s) throughout their hospitalization and connection with community resources and services in the process of complex discharge planning. * Efficient use of healthcare resources by reducing duplication of services and systematically screening for unmet

Who Is Running the Clinical Trial?

University of Calgary

Lead Sponsor

Trials

827

Recruited

902,000+

Canadian Institutes of Health Research (CIHR)

Collaborator

Trials

1,417

Recruited

26,550,000+

Published Research Related to This Trial

In a study analyzing 1009 ICU days, 230 adverse drug events were identified in 79 patients, with the most frequent issues being hypoglycemia, prolonged activated partial thromboplastin time, and hypokalemia.

The occurrence of adverse drug events was significantly linked to higher severity of illness and increased nursing workload, indicating that patient condition and staff demands may influence the safety of drug administration in critical care settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adverse drug events in intensive care units: a cross-sectional study of prevalence and risk factors. Seynaeve, S., Verbrugghe, W., Claes, B., et al.[2013]

A total of 417 adverse event cases leading to death were reported in Brazil from June 2014 to June 2016, primarily affecting adults and the elderly, with hospitals being responsible for 97% of these cases.

The most common incidents were categorized as 'failures during health care,' highlighting a significant need for improved reporting and investigation of such events, as only 5% of cases were further investigated by the notifying units.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Registry of adverse events related to health care that results in deaths in Brazil, 2014-2016. Maia, CS., Freitas, DRC., Gallo, LG., et al.[2019]

A symposium with 31 healthcare professionals highlighted that preventing adverse events in community care requires a multi-faceted approach involving policy changes at various levels, including system integration and improved communication among providers.

Key recommendations from the symposium include prioritizing education for clinicians and caregivers, enhancing organizational culture, and leveraging technology to improve patient safety and reduce adverse events.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adverse events in community care: implications for practice, policy and research. Masotti, P., Green, M., McColl, MA.[2019]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11669714/

Enhancing primary care through integrated care pathways Integrated care pathways (ICPs) are multidisciplinary plans that standardize care, manage patients with specific conditions, and provide a consistent framework ...

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10471334/

Integrated care pathways: a new approach ... - PubMed Central The newly formed integrated care systems (ICSs) is to improve population health and health care, establishing integrated care pathways (ICPs) for patients.

3. health-policy-systems.biomedcentral.com health-policy-systems.biomedcentral.com/articles/10.1186/s12961-024-01260-1

Can integrated care interventions strengthen primary care and ... Integrated care interventions involving primary care can have positive effects on strengthening primary care functions, but these benefits do not necessarily ...

4. sciencedirect.com sciencedirect.com/science/article/pii/S1386505624002867

Flipping healthcare by including the patient perspective in ... This study aims to 1) Identify research approaches taken to develop patient-centred, integrated, care pathways supported by electronic health records.

5. agecymru.wales agecymru.wales/siteassets/documents/reports-and-publications/reports-and-briefings/care--support/rb_may14_cpa_effectiveness_of_care_pathways.pdf

The effectiveness of care pathways in health and social care A 2005 evaluation of the quality of integrated care pathway development in the UK National Health Service found that there was wide variability in the quality ...

6. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC10083780/

Approaches to improving patient safety in integrated care This scoping review aimed to establish the approaches employed to improving patient safety in integrated care for community-dwelling adults ...

7. mayoclinicproceedings.org mayoclinicproceedings.org/article/S0025-6196(25)00218-6/fulltext

Transforming Health Care Through Quality and Safety In this article, we explore how health care can be transformed by integrating key components of quality and safety, such as robust data-driven ...

8. sciencedirect.com sciencedirect.com/science/article/pii/S1553725025001345

A Systems-Based Framework for Integrating Health Equity ... A preliminary framework designed to support health systems in assessing their maturity levels and integrating equity in patient safety in a stepwise manner.

9. aha.org aha.org/guidesreports/2025-03-11-improvement-safety-culture-linked-better-patient-and-staff-outcomes

Improvement in Safety Culture Linked to Better Patient and ... Report shows hospitals outperform pre-pandemic levels, boosting patient safety, care experience and workforce resilience.

10. odphp.health.gov odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/health-care-access-and-quality

Health Care Access and Quality - Healthy People 2030 Healthy People 2030 focuses on improving health by helping people get timely, high-quality health care services.